Provider Demographics
NPI:1952488934
Name:LOURDES OCCUPATIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:LOURDES OCCUPATIONAL HEALTH CENTER
Other - Org Name:LOURDES HEALTH NETWORK
Other - Org Type:Other Name
Authorized Official - Title/Position:CERTIFIED PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMBONE
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:509-546-2222
Mailing Address - Street 1:9915 SANDIFUR PKWY
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-8941
Mailing Address - Country:US
Mailing Address - Phone:509-546-2222
Mailing Address - Fax:509-546-2202
Practice Address - Street 1:9915 SANDIFUR PKWY
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-8941
Practice Address - Country:US
Practice Address - Phone:509-546-2222
Practice Address - Fax:509-546-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001870261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAQ20593Medicare UPIN